Introduction

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) should be suspected in any patient with breast implants and chronic seroma [1,2,3,4]. Most cases have been reported from North America, Europe or Oceania [5,6,7]. In Mexico and Latin America, there is a concern of this pathology.

We reported the first case in Latin America, which was a Mexican patient with a previous history of breast augmentation and liposuction 8 years before the appearance of breast asymmetry due to chronic seroma [8]. The diagnosis was confirmed by the pathologist after several samples without specific diagnoses. At that moment, we did not find any reports of BIA-ALCL from Central or South America.

Brazil and Mexico are important in the world market of texturized breast implants. For this reason, we organized a meeting with the presidents of different plastic surgery societies to discuss this pathology in the region.

Methods

A consensus was achieved with representatives from different plastic surgery societies of the region during our national meeting in Cancun. We had representatives from Argentina, Chile, Colombia, Costa Rica, Guatemala, Mexico, Nicaragua, Panama, Paraguay, Peru, Dominican Republic and Venezuela (Fig. 1).

Fig. 1
figure 1

Banner of the event

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Two participants reviewed the literature before the event. The review was performed using the following information sources: PubMed, Embase, Cochrane, Fisterra, Google Scholar and LILACS. We evaluated articles published from 1980 to August 2015, in several languages (English, Spanish, French and Portuguese).

The MESH language was used to identify keywords in our research. The following keywords were used: lymphoma or non-Hodgkin’s lymphoma or anaplastic large cell lymphoma or ALCL or BIA-ALCL and breast implant or breast prostheses, breast implants or silicones or silicone gel and adverse effects. Article selection: Two researchers reviewed the publications and selected articles based on inclusion and exclusion criteria. The inclusion criteria were cases or a series of cases with at least six of the following variables: age, breast implants, time since implantation and onset of symptoms, implant brand, implant cover characteristics (texturized, non-texturized or polyurethane), biopsy or histopathological study that confirmed the lymphoma diagnosis, markers that were used to perform the diagnosis, surgical treatment, chemotherapy, radiotherapy, follow-up and mortality due to lymphoma associated with breast implants. The exclusion criteria were studies that provided incomplete information or duplicate data for their cases. The results were reported to the participants.

We divided the consensus into two parts. The first part consisted of an open-ended question:

  1. 1.

    Do you know any cases of BIA-ALCL in your country?

  2. 2.

    If the answer is yes, how many confirmed cases do you have?

  3. 3.

    In your country, do you use any medical guidelines to approach any possible cases of BIA-ALCL?

  4. 4.

    Do you have pathologists with enough experience to diagnose these cases in your country?

  5. 5.

    Do you have a reference center for any possible cases in your country?

The second part consisted of clinical scenarios, each scenario with questions and answers numbered from 1 to 10 with scores of 1–3 indicating disagreement, 4–7 uncertainty and 8–10 agreement. Each question had a final grade rating.

The main questions from the clinical scenarios were as follows:

  1. 1.

    At the time of removing or changing breast implants in an asymptomatic patient with chronic seroma, what is the importance of sending samples to laboratory and pathology? Nothing, culture, histochemistry, pap smear, pathology sample, markers.

  2. 2.

    A patient with history of breast implants (placed more than 1 year ago) comes to the clinic for an increase in breast tissue volume. What will be the clinical findings that you will investigate? Breast asymmetry, nodes, inflammation.

  3. 3.

    In the same patient, what type of breast imaging will you propose? Nothing, ultrasound, CT scan, MRI.

  4. 4.

    What will be your treatment if fluid (seroma) is found in the studied breast? Wait for spontaneous resolution, antibiotic and anti-inflammatory drugs, puncture-guided surgical aspiration.

  5. 5.

    Once the fluid has been aspirated, what type of study will you order? Nothing, culture, pap smear, immunomarkers, immunohistochemistry.

  6. 6.

    Do you agree to order the following test to identify possible bacteria or biofilm? Sonication, normal culture, anaerobe culture, mycobacteria, PCR for mycobacteria.

  7. 7.

    If after seroma aspiration, the patient returns because of persistence of the problem, what will be your approach? Implant removal of the affected side, implant removal both sides, exchange implant, fluid aspiration, capsulectomy, nodes exploration.

  8. 8.

    What type of study will you order for the capsule? None, culture, histopathology, immunomarkers.

  9. 9.

    Once the implant is removed, what findings will you look for in the implant? Integrity, site of rupture, opacity, type of implant (silicone, saline), type of coverage (smooth and texture), brand, timing of implantation.

  10. 10.

    In cases of suspected BIA-ALCL, in addition to the pathology report, what type of clinical findings will you record? Age, race, location of pocket, past history of drains, antibiotics, past history of seroma, type of incision.

Results

In total, 172 publications were identified; according to the inclusion and exclusion criteria, information from 42 articles was discussed with the panelists [8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49] including representatives of plastic surgery societies from Argentina, Colombia, Costa Rica, Guatemala, Mexico, Nicaragua, Panama, Paraguay, Peru, Dominican Republic and Venezuela.

Representatives from three societies confirmed at least one case of BIA-ALCL (Chile 3, Mexico 3 and Argentina 1). Fifty percent of the representatives reported that they would consult with a center to follow guidelines for approach and treatment. All participants were informed about the relationship between BIA-ALCL and chronic seroma. The subject has been discussed in the meetings in the region.

Table 1 shows the results of the second part of the study.

Table 1 Results of the second part of the study
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Discussion

BIA-ALCL is a rare malignancy arising in an effusion or capsule in breast prosthesis.

The causes of this pathology are debatable and include, for example, biofilm due to bacteria, the surface of the implant or a possible genetic predisposition. [17, 25, 50, 51]. This condition drew our attention because in South America, we observed more reports than those in other countries with smaller populations. It is true that some authorities play an important role in recording cases and providing important information about this pathology, and some others work in close contact with different societies [5]. Specifically, in Mexico, we have organized sessions, meeting and guidelines because we represent an important market for texture implants, and we only have information from three cases, the first of which was reported to the companies 2 years ago [8].

Since the first report, we have seen an increase in the information about this matter [52]. More recent studies in our population will help to clarify the possible causes, including the genetic or demographic factors that may play a role in this pathology. We are working together with other plastic surgery societies including the Global Network of BIA-ALCL. This is a group of experts from different parts of the world who are joining efforts, knowledge and experience in this subject. As mentioned by Clemens and colleagues, it is extremely important to mention the possibility of this problem in the informed consent [53].

We have instructed plastic surgeons to be aware about the possibility of chronic seroma in any patient with breast asymmetry after 1 year of implantation. Additional findings including nodes, contracture and masses should also be determined [1,2,3,4].

It is important to mention that not all the cases of chronic seroma are ALCL, but the most common symptom of ALCL is chronic seroma [54] [56] (Fig. 2). The cases that we know of from our region were diagnosed by persistence of the seroma and high suspicion from the plastic surgeon. Our suggestion in the case of chronic seroma is to take a sample by puncture-guided ultrasound and to work with an experienced pathologist. In cases of high suspicion even after a negative result, we should consider bilateral removal and capsulectomy to help make diagnoses and guide important steps in treatment.

Fig. 2
figure 2

Algorithm for the management of chronic seroma in patients with breast implants. Chronic seroma is defined as one that occurs after 1 year from the placement of breast implants

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Most of the information comes from other countries, and we are aware of this, so we are making an effort to join all the possible cases with the same group of specialists to provide the same treatment. We should not forget that cancer treatment has changed in recent years. New biological treatments have come into the field [55].

Traditionally, surgery has been the key treatment of many cancers, for example, breast cancer. Currently, new treatments have come into use. Specific markers, such as Her2, have become important, and trastuzumab has become one of the main treatments in the field [56]. Brentuximab has become a new option to treat BIA-ALCL, and for this reason, it is very important that every society, medical authority and country has a pathologist capable of confirming diagnoses using proper markers such as CD30 and ALK. Immunology is receiving more attention as a promising treatment option to help patients with advanced stage cancer.

BIA-ALCL is not as common as breast cancer, and for this reason, we encourage that in any suspected case of BIA-ALCL, the patient should be oriented to a multidisciplinary treatment approach where the plastic surgeon can help to make right diagnosis [57]. We have seen that it is not common for the pathologist to study this problem. In South and Central America, we know that pathologists are not familiar, so if the problem persists (seroma), we can collaborate to rule out this entity. In Mexico, it was necessary to take more than one sample to rule out this problem in the first case. We also know this is not the same problem as there is in other countries at this moment.

The topic seems to be popular in social media and the news. We need to be careful how we handle this problem and how we inform our patients.

Conclusion

BIA-ALCL is receiving increased attention among different societies in the region. More efforts to create a multidisciplinary team will improve awareness of this problem. All participants agreed that the manner in which chronic seroma is approached needs to be changed, and efforts to consult with a multidisciplinary team will help to make the correct diagnoses and treatment.